Provider Demographics
NPI:1639251051
Name:KEVIN R WADDELL MD PA
Entity Type:Organization
Organization Name:KEVIN R WADDELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-212-1000
Mailing Address - Street 1:740 HOSPITAL DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4664
Mailing Address - Country:US
Mailing Address - Phone:409-212-1000
Mailing Address - Fax:409-212-1003
Practice Address - Street 1:740 HOSPITAL DR
Practice Address - Street 2:SUITE 250
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4664
Practice Address - Country:US
Practice Address - Phone:409-212-1000
Practice Address - Fax:409-212-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4976207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184820201Medicaid
TX184820202Medicaid
TX184820201Medicaid